New Passion Home Care

Education

High School

High School name : * City, State : * Graduated : * Degree or Major : *

College

College name : City, State : Graduated : Degree or Major :

Other

Name : City, State : Graduated : Degree or Major :

Computer Skills

Typing : * List some software packages with which you have experience *

Background Information

When completing this section, do not disclose information regarding convictions that have been judicially erased, sealed, eradicated, impounded or dismissed. Do not disclose information regarding juvenile court convictions or minor civil traffic violations. A conviction record does not automatically bar you from employment. All of the job-related circumstances surrounding convictions will be considered.

1. In the last 7 years, have you been convicted of, pled guilty or no contest to, been imprisoned, or on probation or parole for any felony?

2. In the last 7 years, have you been convicted of, pled guilty or no contest to, been imprisoned, or on probation or parole for any misdemeanor?

3 Do you currently have felony charges pending? Yes No *

4 Are you currently on probation? Yes No *

Previous Employment

From : *

To : *

Job Title : *

Immediate Supervisor and Title : *

Reason For Leaving *

Employer : *

Phone : *

Address : *

Nature of Work and Responsibilities : *

Hourly Rate Salary : *

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Immediate Supervisor and Title :

Reason For Leaving

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Address :

Nature of Work and Responsibilities :

Hourly Rate Salary :

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Reason For Leaving

Employer :

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Authorization and Understanding

By signing this application, I AGREE that all of the information now or later given by me in support of my application for employment is true and complete. I understand that you may verify any of the information concerning my employment, education or medical history with the appropriate individuals, or organizations, or governmental agencies. I give these individuals, organizations, or governmental agencies my permission to release any information that you need, including my previous disciplinary record, without requiring them to contact me or give me written notice before revealing the information to you.

I AGREE that either party may terminate the employment relationship, with or without cause, at any time, for any reason, and I further agree that this arrangement may only be changed by the president of the company, in writing, directed to me personally, and signed by the president of the company. I agree that I shall be bound by the other rules, policies, regulations, and terms and conditions of employment of the Company as they are from time to time changed and that no additional obligations can be imposed by me on the Company except those which have been acknowledged, in writing, by the Company President or his/her designated representative. I further agree that my employment is conditional upon satisfactory completion of documentation as required b the Immigration Reform and Control Act of 1986 and until such time as the results of my pre-employment physical (if such physical is required) are known.

I AGREE THAT ANY CLAIM OR LAWSUIT RELATING TO MY SERVICE WITH THE COMPANY OR ANY OF ITS SUBSIDIARIES MUST BE FILED NO MORE THAT SIX (6) MONTHS AFTER THE DATE OF EMPLOYMENT ACTION THAT IS THE SUBJECT OF THE CLAIM OR LAWSUIT. I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.

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Thank you for your interest to be part of our family. Our Human Resource department will review your application along with your qualifications, and we hope to be in touch with you soon.New Passion Home Care is committed to employ and treat persons without regard to race, color, gender, religion, sex, national origin, age, marital status, sexual orientation, disability, veterans' status, or any other protective status except where there is a bona fide occupational qualification.

New Passion Home Care believes in having the responsibility of employing and retaining a exceptional staff, which is current in its knowledge, application(s), and conceptualization of professional practices, and above all the passion to care for patients like family. We believe our staff should be skilled in making professional judgments, in applying treatment modalities and programs with individual clients and patients.

We hope you are excited as we are to be in touch with you soon.

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